Paul M. Tsou

Posterolateral Endoscopic Excision for Lumbar Disc Herniation: Surgical Technique, Outcome, and Complications in 307 Consecutive Cases

Study Design. A retrospective review involving 307 consecutive cases of lumbar disc herniation managed by posterolateral endoscopic discectomy was conducted. Objectives. To describe a contemporary posterolateral endoscopic decompression technique for radiculopathy secondary to lumbar disc herniation; to evaluate the efficacy of the technique as it is applied to lumbar disc herniation including primary herniation, reherniation, intracanal herniation, and extracanal herniation; and to report outcome and complications. Summary of Background Data. The concept of percutaneous posterolateral nucleotomy was introduced in 1973. The development of the related equipment and technique had witnessed a slow and lengthy evolution. Method. A retrospective assessment of 307 patients was performed at least 1 year after their index operation. The outcome was graded according to a modified MacNab method. A patient-based outcome questionnaire also was incorporated into the study. Results. The surgeon-performed assessment showed satisfactory results in 89.3% of the cases. The rate of response to the questionnaire was 91%. The responses indicated that 90.7% of the respondents were satisfied with their surgical outcome and would undergo the same endoscopic procedure again if faced with a similar herniation in the future. The poor outcome occurred in 10.7% of the primary group and 9.7% of the questionnaire group. The combined major and minor complication rate was 3.5%. Conclusions. The surgical outcome of posterolateral endoscopic discectomy for lumbar disc herniation is comparable with that for the traditional open transcanal microdiscectomy. Intracanal and extracanal herniations, reherniations, and incidental lateral recess stenosis can be addressed by the same approach.

Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: outcome and technique.

BACKGROUND CONTEXT In 1973 Kambin and Gellman introduced the concept of percutaneous posterolateral extracanal approach in the management of radiculopathy secondary to lumbar disc herniation (LDH). This new surgical approach was recognized as potentially even less invasive compared with the microscope-assisted transcanal technique. However, the development of the posterolateral extracanal approach has witnessed a slow and complicated technique and equipment evolution. PURPOSE To report the surgical outcome, complications and technique of decompressing radiculopathy secondary to noncontained intracanal LDH using percutaneous extracanal access, the transforaminal endoscopic approach. STUDY DESIGN/SETTING Consecutive cases of LDHs from L3-S1 who had at least 1-year postoperative follow-up were included in this retrospective review. PATIENT SAMPLE Two hundred nineteen patients met inclusion criteria. There were 136 (62.1%) male patients, average age 41.5 years, and 83 (37.9%) female patients, average age 42.5 years. The age range was 17 to 71 years. METHODS Two outcome measures were used. The first part was a surgeon-performed assessment. The second used a patient-based outcome questionnaire. OUTCOME MEASURES The surgeons retrospective assessment of excellent, good, fair and poor is a modified MacNab classification. The same terminology is used in the patient-based outcome questionnaire. Poor outcome resulting from technique failure is identified. RESULTS Two hundred nineteen patients met the inclusion criteria. One hundred ninety-three patients also send back their completed questionnaire. The surgeon graded 88% percent of the 219 patients had a good or excellent result and the questionnaire subgroup 91.2%. The fair results were 5% of the 219 patients, 3.6% for the questionnaire patients. The poor results were 6.8% of the 219 patients and 5.2% for the questionnaire subgroup. The overall complication rate was 2.7% and missed fragment rate 0.9%. CONCLUSIONS Noncontained intracanal LDH fragments are accessible using the transforaminal endoscopic technique and equipment described. Retrospective outcome reviews of our clinical material showed results comparable to the reported findings in the literature for both the endoscopic and open transcanal decompression techniques.

Clinical studiesTransforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: outcome and technique☆☆☆

BACKGROUND CONTEXT In 1973 Kambin and Gellman introduced the concept of percutaneous posterolateral extracanal approach in the management of radiculopathy secondary to lumbar disc herniation (LDH). This new surgical approach was recognized as potentially even less invasive compared with the microscope-assisted transcanal technique. However, the development of the posterolateral extracanal approach has witnessed a slow and complicated technique and equipment evolution. PURPOSE To report the surgical outcome, complications and technique of decompressing radiculopathy secondary to noncontained intracanal LDH using percutaneous extracanal access, the transforaminal endoscopic approach. STUDY DESIGN/SETTING Consecutive cases of LDHs from L3-S1 who had at least 1-year postoperative follow-up were included in this retrospective review. PATIENT SAMPLE Two hundred nineteen patients met inclusion criteria. There were 136 (62.1%) male patients, average age 41.5 years, and 83 (37.9%) female patients, average age 42.5 years. The age range was 17 to 71 years. METHODS Two outcome measures were used. The first part was a surgeon-performed assessment. The second used a patient-based outcome questionnaire. OUTCOME MEASURES The surgeons retrospective assessment of excellent, good, fair and poor is a modified MacNab classification. The same terminology is used in the patient-based outcome questionnaire. Poor outcome resulting from technique failure is identified. RESULTS Two hundred nineteen patients met the inclusion criteria. One hundred ninety-three patients also send back their completed questionnaire. The surgeon graded 88% percent of the 219 patients had a good or excellent result and the questionnaire subgroup 91.2%. The fair results were 5% of the 219 patients, 3.6% for the questionnaire patients. The poor results were 6.8% of the 219 patients and 5.2% for the questionnaire subgroup. The overall complication rate was 2.7% and missed fragment rate 0.9%. CONCLUSIONS Noncontained intracanal LDH fragments are accessible using the transforaminal endoscopic technique and equipment described. Retrospective outcome reviews of our clinical material showed results comparable to the reported findings in the literature for both the endoscopic and open transcanal decompression techniques.

A comprehensive subaxial cervical spine injury severity assessment model using numeric scores and its predictive value for surgical intervention.

Multiple factors contribute to the determination for surgical intervention in the setting of cervical spinal injury, yet to date no unified classification system exists that predicts this need. The goals of this study were twofold: to create a comprehensive subaxial cervical spine injury severity numeric scoring model, and to determine the predictive value of this model for the probability of surgical intervention. In a retrospective cohort study of 333 patients, neural impairment, patho-morphology, and available spinal canal sagittal diameter post-injury were selected as injury severity determinants. A common numeric scoring trend was created; smaller values indicated less favorable clinical conditions. Neural impairment was graded from 2-10, patho-morphology scoring ranged from 2-15, and post-injury available canal sagittal diameter (SD) was measured in millimeters at the narrowest point of injury. Logistic regression analysis was performed using the numeric scores to predict the probability for surgical intervention. Complete neurologic deficit was found in 39 patients, partial deficits in 108, root injuries in 19, and 167 were neurologically intact. The pre-injury mean canal SD was 14.6 mm; the post-injury measurement mean was 12.3 mm. The mean patho-morphology score for all patients was 10.9 and the mean neurologic function score was 7.6. There was a statistically significant difference in mean scores for neural impairment, canal SD, and patho-morphology for surgical compared to nonsurgical patients. At the lowest clinical score for each determinant, the probability for surgery was 0.949 for neural impairment, 0.989 for post-injury available canal SD, and 0.971 for patho-morphology. The unit odds ratio for each determinant was 1.73, 1.61, and 1.45, for neural impairment, patho-morphology, and canal SD scores, respectively. The subaxial cervical spine injury severity determinants of neural impairment, patho-morphology, and post-injury available canal SD have well defined probability for surgical intervention when scored separately. Our data showed that each determinant alone could act as a primary predictor for surgical intervention.

Posterolateral percutane endoscopic lumbar discectomy

Abstract The technique and equipment for performing posterolateral percutaneous endoscopic lumbar discectomy underwent a slow evolution in the past 30 years. The current level of proficiency was reached about 5 years ago. As a result, the endoscopic capabilities closely overlapped that of conventional transcanal open operations for herniated lumbar disc. Endoscopic technique has the unique ability to visualized and treat certain intradiscal pathology. Intradiscal visualization is enhanced by staining with 10% to 20% indigocarmine dye. This blue dye differentially stains degenerated nucleus and granulation tissue in annular defects. Biplane c-arm images are used for percutaneous guidance. The approach trajectory starts from an optimally located skin window entering the disc through the foraminal annular window. Normally there are limited endoscopic workspaces. A working tunnel, working cavity must be created for viewing and manipulating operating tools. Currently available equipment includes a high-resolution rod lens operating endoscope, bevel cannula, bipolar radiofrequency electrode, and a side-firing Holmium-yttrium-aluminum-garnet laser. Each has a unique role in performing special tasks. The learning curve is steep but once mastered, the surgeon is able to extract contained and noncontained disc herniations. Granulation tissue in annular defects is ablated using radiofrequency electrode. Holmium-yttrium-aluminum-garnet laser has a unique ability in dividing thick collagenous tissue and ablating cortical bone.